Hemodynamic evaluation and monitoring in the ICU

Hemodynamic monitoring, a cornerstone in the management of the critically ill patient, is used to identify cardiovascular insufficiency, its probable cause, and response to therapy. Still it is difficult to document the efficacy of monitoring because no device improves outcome unless coupled to a treatment that improves outcome. Several clinical trials have consistently documented that preoptimization for high-risk surgery patients treated in the operating room and early (< 12 h) goal-directed resuscitation in septic patients treated in the emergency department reduce morbidity, mortality, and resource use (costs) when the end points of resuscitation were focused on surrogate measures of adequacy of global oxygen delivery (Do2). The closer the resuscitation is to the insult, the greater the benefit. When resuscitation was started after ICU admission in high-risk surgical patients, reduced length of stay was also seen. The focus of these monitoring protocols is to establish a mean arterial pressure > 65 mm Hg and then to increase Do2 to 600 mL/min/m2 within the first few minutes to hours of presentation. To accomplish these goals, hemodynamic monitoring focuses more on measures of cardiac output and mixed venous oxygen saturation to access adequacy of resuscitation efforts than on filling pressures. Although these protocols reduce mortality and morbidity is selected high-risk patient groups, the widespread use of monitoring-driven treatment protocols has not yet happened, presumably because all studies have been single-center trials using a single, proprietary blood flow-monitoring device. Multicenter trials are needed of early goal-directed therapies for all patients presenting in shock of various etiologies and when the protocol and not the monitoring device is the primary variable.